Double-barrel vascularised fibula graft in mandibular reconstruction: A 10-year experience with an algorithm

Technical procedures for template-guided surgery for mandibular reconstruction based on digital design and manufacturing

“…For free fibular flap reconstruction, the rules of graft site selection, resection, and shaping are determined by the requirements of harvesting on hard and soft tissue (mucosa or skin) [4]: (1) The vascular pedicle for supplying blood to the graft flap should be carefully maintained during surgery; (2) mandibular bone height should be restored by graft, so a “double-barrel” approach may be adopted; (3) for reconstruction of the mandibular ramus, the third “barrel” is needed, so the resection template should satisfy these requirements; and (4) to restore the patient’s appearance, the graft should be shaped by a shaping template.To harvest an ideal graft, four steps are required: (1) A preliminary plan for graft placement is designed based on the measurement of defect size, and so the length and angle of fibular barrels are initially planned; (2) the fibular model is moved to the mandibular defect area; (3) the fibular model is cut into needed barrels, which are transferred to new positions according to the initial plan; and (4) the positions of the barrels are carefully adjusted, with step 3 repeated if necessary, to obtain an ideal plan for graft shape and placement. In this case, the fibula was cut into 3 segments, 2 of which were placed as double barrels for alveolar bone restoration in the left jaw, with the third segment positioned for mandibular left ramus reconstruction.…”

“…Reconstruction of the mandibular defect has been performed by various techniques including iliac bone grafts, costochondral grafts, a sliding vertical osteotomy on the posterior border of the mandibular ramus, sternoclavicular grafts, scapular flaps [1], and vascularized second metatarsal joint grafts [2]. Hidalgo introduced the vascularized fibular graft, which became the gold standard for the reconstruction of the mandibular condyle [3], because it offers several advantages: it can supply a large amount of bone and soft tissue for harvest [4]; the vessel pedicle is generally long and anatomically reliable; furthermore, this procedure involves only minor donor site morbidity, with no requirement for patient repositioning during surgery [5]. …”

Microsurgical free flap reconstructions of the head and neck region: Shanghai experience of 34 years and 4640 flaps

“…In our department, the double-barrel technique was first applied by Prof. Sun. 6 In some cases, however, the double-barrel technique still cannot meet the requirements for successful implant therapy due to its limited length. To improve on this, Professor Chen-ping Zhang of our department has devised a dental implant distractor (DID) technique in which the fibula is vertically distracted simultaneously with dental implant placement.…”

“…Once the origin of the 6 Zhang et al Total perforator is confirmed, and vascular pedicle can be dissected; in order to enable direct closure of the wound at the donor site, the width of the flap should not be more than 10 cm. For a large defect with a length greater than 20 cm or a width greater than 10 cm, a latissimus dorsi myocutaneous flap can be used.…”

The Fusion of Craniofacial Reconstruction and Microsurgery

“…65 A "doublebarrel flap" or vertical distraction of the flap has been described to compensate for this limitation, although this is rarely used by our institution, in part because of modern prosthetics that compensate for bony height. [66][67][68] Of the two flap choices preferred, the iliac crest flap provides a contour that resembles the native mandible. For this reason, it is our flap of choice for limited, unilateral defects extending from the parasymphysis to the ramus.…”